Complete the sections below, attach electronic copies of your receipts and click submit for your claim to be processed.

Personal Details

Drug Claims:

List all prescriptions purchased. Please attach receipts for every expense. Attach your physician's written recommendation and diagnosis where applicable.

Note: All fields are required except for Dispensing Fee

Note: Touch title area to scroll.

Name of Patient

Birth Date

Relation to Member

Date of Expense

DIN

Dispensing Amount Fee

Amount Charged (Drug Cost) 

Total Charged

Attach Receipt Images
Maximum 4Mb File Size per Attachment


Medical and Vision Claims:

List all services and/or items purchased. Please attach receipts for every expense. Attach your physician's written recommendation and diagnosis where applicable.

Note: All fields are required

Note: Touch title area to scroll.

Name of Patient

Birth Date

Relation to Member

Date of Expense

Type of Expense

Subtype

Total Charged

Attach Receipt Images
Maximum 4Mb File Size per Attachment


Dental Claim:

Complete all sections in the form below for each dental procedure. Attach a copy of the dental claim statement provided by your dental office.

Note: All fields are required except for Lab Charge, Tooth Surface and Tooth Code (provide these if available)

Note: Touch title area to scroll.

Name of Patient

Birth Date

Relation to Member

Date of Service

Procedure Code
(5 digit)

Tooth Code

Tooth Surface

Lab Charge
(If applicable)

Dentist's Fee

Total Charged

Attach Receipt Images
Maximum 4Mb File Size per Attachment


Coordination of Benefits


Health Care Spending Account (Expenses must be eligible under the Income Tax Act)

  1. Please attach receipts, or if expenses have been submitted under this or another plan and you are now claiming for the unpaid portion, please attach receipts plus the Explanation of Benefits from the previous submission
  2. Please indicate whether you want:

Or

Attach Receipt Images
Maximum 4Mb File Size per Attachment


Notes